PCGHD Phase 1B COVID-19 Vaccine Registration
Please register using this survey so we can develop a schedule to make vaccine distribution quick and efficient. Once vaccine is available and ready to administer, you will receive an email from us with the time/date/location regarding your COVID-19 Vaccination.
Name * *
Home Address *
Email Address *
Phone Number *
Date of Birth *
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Name of Employer
Employer Address
Job Title
Work phone number
Retired
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Please select the Phase 1B population you fall under: *
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Please list any known allergies. *
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